Healthcare Provider Details

I. General information

NPI: 1437817616
Provider Name (Legal Business Name): TRACY JACKSON SNYDER LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 E JACKSON BLVD BLDG B
ERWIN NC
28339-9629
US

IV. Provider business mailing address

596 E JACKSON BLVD BLDG B
ERWIN NC
28339-9629
US

V. Phone/Fax

Practice location:
  • Phone: 910-897-2008
  • Fax: 910-897-2009
Mailing address:
  • Phone: 910-897-2008
  • Fax: 910-897-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-30728
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: